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[Reprinted  from  New  York  State  Journal  of  Medicine, 
January,  1911 .] 


THE  CARE  AND 
EPILEI 


IAN,  M.D., 


By  WM.  T.  SHANAHA 


u 


SONYEA,  N.  Y. 


HE  term  “epilepsy”  refers  to  a group  of 


symptoms  which  are  the  clinical  expression 


of  various  underlying  conditions;  e.  g., 
structural  stigmata  of  defectiveness;  degenera- 
tive ..  cardio-vascular  disease ; focal  organic" 
disease  of  the  brain ; toxic  states  and  those 
arising  without  any  tangible  cause ; i.  e.,  the  idio- 
pathic epilepsies.  » 

The  syndrome  may  be  defined  as  a chronic/ 
progressive  disorder,  with  a symptom  complex, 
characterized  by  recurrent  abrupt  seizures  of 
impairment  or  loss  of  consciousness,  with  or 
without  convulsions  and  usually  producing 
mental  and  oftentimes  physical  deterioration. 

The  time  allowed  me  is  too  brief  to  refer  at 
length  to  diagnosis,  but  I wish  to  call  attention 
to  the  fact  that  frequently  the  early  manifesta- 
tions remain  unrecognized  for  years.  The 
various  types  of  mild  and  incomplete  seizures 
lire  too  commonly  ascribed  to  other  causes.  The 
borderland  cases  require  long  and  careful 
observation  before  a definite  diagnosis  can  be 
arrived  at. 

* Read  in  abstract  before  the  Seventh  District  Branch  at 
Geneva,  N.  Y.,  September  15,  1910.  , 


The  etiology  of  epilepsy  is  apparently  as 
complex  as  it’s  phenomena.  The  difficulty  in 
obtaining  correct  information  from  relatives  or 
friends  in  regard  to  alcoholism,  syphilis,  in- 
sanity and  similar  conditions  is  marked  and 
oftentimes  well  nigh  impossible.  They  feel  that 
some  of  these  matters  should  be  concealed  from 
everyone,  even  the  physician.  In  many  cases, 
there  is,  of  course,  a complete  or  practically  com- 
plete ignorance  of  facts  concerning  the  exact 
state  of  health  of  living  members  and  the  cause 
of  death  of  those  not  living.  The  family 
physician  is  sometimes  guilty  of  either  aiding 
the  family  in  concealing  some  important  in- 
formation, or  he  is  careless  in  pressing  . suffi- 
ciently hard  to  obtain  the  requisite  facts  which 
have  a bearing  on  the  case  in  question.  He 
is  sometimes  afraid  to  offend  the  relatives  by 
asking  for  such  information.  If  he  uses  proper 
tact  and  judgment,  he  can  in  practically  every 
case,  secure  from  the  relatives  all  of  the  infor- 
mation within  their  knowledge  regarding  the 
case.  This  total  information  is  in  many  patients 
painfully  meagre  and  sometimes  even  nil. 

The  consensus  of  opinion  at  the  present  time 
is  that  true  epilepsy  is  indicative  of  a family 
neuropathic  degeneration.  There  are  often 
present  other  hereditary  degenerative  conditions 
such  as  stammering,  backwardness  in  walking 
and  talking,  delayed  dentition,  deafmutism, 
imbecility,  etc. 

Eighty-five  per  cent,  of  all  cases  appear  be- 
fore the  twentieth  year  of  age,  thus  showing 
itself  as  essentially  a malady  of  the  period  of 
development  and  growth  of  the  central  nervous 
system.  It  is  during  these  years  that  the 
nervous  instability  acquired  by  heredity  is  most 


2 


t?  m tj  fiMM. 


'BVn  \ 


effective;  and  it  is  during  this  period  of  life 
that  causes  altogether  insignificant,  or  insuf- 
ficient in  stable  nervous  systems,  may  light  up 
the  tendency  to  the  impairment  of  consciousness 
with  the  convulsions,  which  characterize  this 
malady.  Many  explanations  are  given  by  the 
patient  or  his  friends  or  relatives  as  to  the  cause 
of  onset,  but  these  in  most  cases,  are  but  con- 
jectural. The  essential  cause  and  real  explana- 
tion is  thought  to  be  found  in  the  rapid  growth 
during  the  first  few  years  of  life,  the  onset  of 
puberty  and  accompanying  changes  in  persons 
predisposed  by  heredity  to  nervous  instability  and 
V>  convulsions. 

In  these  individuals  a convulsive  habit  may  be 
established  either  in  course  of  natural  develop- 
ment, or  as  a result  of  certain  occasional  or 
accidental  causes.  Once  the  convulsive  habit  has 
been  established,  there  is  a tendency  to  its  per- 
petuation in  the  form  of  recurring  epileptic 
seizures.  Thus  infantile  convulsions  are  fre- 
quietly  the  starting  point  of  a subsequent 
epilepsy,  either  as  a direct  sequence  of  the  con- 
vulsions, or  in  later  years  at  or  about  the  onset  of 
puberty.  The  great  majority  of  the  cases  of 
infantile  cerebral  palsy  have  convulsions  in 
later  life.  Convulsions  occurring  as  a result  of 
, the  exanthemata,  acute  infective  disorders  and 
disorders  due  to  toxic  influences  are  often  to  be 
regarded  as  manifestations  of  an  acute  epilepsy. 

Convulsions  arising  as  a result  of  trauma  to 
the  head,  without  organic  disease  of  the  brain, 
> are  of  a similar  character,  but  less  acute  in  onset. 
The  convulsions  induced  by  traumatic  lesions  of 
the  brain,  by  coarse  lesions  of  a vascular,  more 
especially  syphilitic,  nature  and  those  of  organic 
cerebro-cortical  disease,  particularly  tumor,  may 


3 


be  forerunners  of  genuine  epileptic  seizures, 
which  persist  even  after  the  exciting  cause  has 
been  medicinally  or  surgically  removed. 

The  convulsions  of  later  life,  as  are  seen  in 
the  so-called  “senile  epilepsy,”  and  in  those 
associated  with  cerebral  thrombosis  or  hemor- 
rhage, are  thought  to  point  to  the  existence  of  a 
latent  convulsive  tendency,  which  is  only  brought 
into  prominence  by  an  accidental  circumstance, 
or  constitutional  cause. 

Those  individuals  who  become  epileptic  do  so, 
in  all  probability,  because  of  some  primary 
defect  in  development  of  the  brain  which  renders 
the  cortical  cells  so  unstable  that  they  re-act 
abnormally  to  various  stimuli.  As  time  goes  on, 
this  instability  becomes  more  marked  in  con- 
sequence of  structural  changes  imposed  upon  the 
primary  defect. 

Regarding  the  use  of  alcohol,  it  is  not  the 
quantity  of  alcohol  ingested  that  is  important, 
but  it  is  the  reaction  of  the  individual  case  to  the 
alcohol  ingested.  One  person  might  consume 
large  quantities  and  suffer  less  damage  than 
another  taking  a much  smaller  quantity  of  a 
milder  intoxicant.  Each  case  is  a study  in  itself 
when  the  question  of  transmitted  weakness  as  a 
result  of  alcohol  is  to  be  considered. 

In  very  few  cases  of  epilepsy  seen  in  our 
public  institutions,  can  we  obtain  a history  of 
specific  disease  in  the  parent,  nor  can  we  find 
in  the  patient  manifestations  of  hereditary 
lues.  Most  authorities  have  claimed  that  the 
percentage  of  cases  due  to  hereditary  syphilis  is 
small. 

The  role  played  by  hereditary  syphilis  in  the 
production  of  epilepsy  is  difficult  to  ascertain 
definitely.  With  the  Wassermann  and  Noguchi 


4 


tests  more  evidence  has  been  uncovered  to  prove 
that  syphilis  is  present  in  a considerable  percent- 
age of  our  defective  classes,  among  whom,  of 
course,  are  included  epileptics.  So  many  preg- 
nancies in  syphilitic  mothers  fail  to  come  to  term 
or  if  the  child  is  born,  have  but  a brief  existence, 
that  we  would  not  expect  to  find  this  underlying 
factor  in  the  majority  of  older  defectives. 

Hochsinger,  investigating  the  fate  of  children 
whose  parents  had  contracted  syphilis  before 
marriage  (J.  A.  M.  A.,  Vol.  55,  p.  616),  studied 
139  families  of  the  better  class  with  569  children. 
These  139  women  had  263  syphilitic  infants  born 
alive,  253  dead  babies  and  53  living  non-syphil- 
itic children.  Of  the  263  affected  children,  55 
died  before  reaching  four  years,  thus  leaving 
208  under  prolonged  observation.  Hospital  sta- 
tistics show  that  70  per  cent,  of  all  syphilitic 
babies  die  in  their  first  year.  Hochsinger  claims 
the  first  born  child  is  most  affected,  the  second 
less,  and  so  on.  Where  maternal  lues  was 
present,  the  children  were  more  liable  to  be 
affected.  He  feels  that  an  energetic,  long- 
continued  anti-syphilitic  treatment  may  do  much 
good  for  these  children. 

As  stated,  we  do  occasionally  find  that  in 
acquired  syphilis,  phenomena  present  themselves 
which  cause  the  physician  to  diagnose  epilepsy. 
Anti-syphilitic  medication,  in  some  cases,  pro- 
duces excellent  results ; in  others  its  effect  is  niL- 

The  conclusions  to  be  drawn  from  our  present 
knowledge  of  the  possible  influence  of  etiological 
factors  in  epilepsy  are  as  follows : 

1.  Epilepsy,  feeblemindedness,  insanity,  alco- 
holism and  similar  disorders,  when  present  in 
antecedents  have  a deleterious  influence  on  a 


large  percentage  of  descendants,  especially  when 
in  the  direct  line. 

2.  The  deleterious  influence  manifests  itself 
either  by  mental  deficiency,  physical  abnormality 
or  as  one  of  the  symptom  complexes  as  epilepsy, 
insanity,  etc. 

3.  Uniform  and  exhaustive  methods  of  study- 
ing heredity  along  lines  now  being  mapped  out 
must  be  obtained  before  our  statistics  will  be  of 
great  value. 

4.  The  destructive  influence  of  alcohol,  syphilis, 
the  various  infectious  diseases,  rickets,  trauma, 
etc.,  on  the  central  nervous  system  is  unques- 
tioned. These  pave  the  way  for  epilepsy  in  the 
individual  himself  as  well  as  in  his  progeny.  • 

5.  The  epilepsies  are  as  a rule  but  evidence  of 
a subnormal  individual. 

The  present  opinion  as  regards  our  knowledge 
of  epilepsy,  is  that  there  are  no  definite  facts  as 
to  its  exact  cause,  but  at  the  same  time,  among 
those  who  have  carefully  studied  the  matter, 
there  is  quite  a general  consensus  of  opinion  that 
the  symptom  complex  is  of  toxic  or  autotoxic 
origin.  The  analogy  of  the  cell  changes  in 
epilepsy  to  those  produced  by  the  toxic  agents 
lends  much  force  to  this  opinion. 

As  to  the  pathology  of  epilepsy,  we  must  in  a 
large  part  agree  with  Reynolds,  who  wrote  in 
the  early  sixties,  that  pathological  anatomy,  has 
shown  three  things ; first,  that  there  is  scarcely 
any  morbid  condition  which  may  not  be  found 
sometimes  in  the  bodies  of  epileptics,  second, 
that  no  structural  change  is  constantly  found  at 
all  periods  of  the  disease,  third,  that  some  lesions 
are  of  more  common  occurrence  than  others  and 
that  many  lesions  have  no  causal  relation  to  the 


6 


phenomena  of  epilepsy  and  that  many  of  these 
lesions  must  be  duly  regarded  as  its  effects. 

Hughlings  Jackson’s  theory  is  that  epilepsy  is 
more  often  due  to  a condition  of  specific  systemic 
poisoning,  a condition  in  which  deep-seated 
errors  exist  in  the  fundamental  principles  of 
metabolism,  in  the  ultimate  cell  life ; and  which 
errors  are  so  serious  from  time  to  time  and  at 
irregular  intervals  that  a positive  universal  con- 
dition is  the  result,  which  toxic  condition  varies 
in  intensity  in  the  same  individual  at  different 
times,  as  it  must  to  produce  attacks  of  epilepsy 
alternately  so  unlike  and  so  varied  in  character. 

Many  claim  that  epilepsy  is  due  to  some  toxic 
substances  circulating  in  the  blood.  Inasmuch 
as  seizures  similar  to  those  observed  in  epilepsy 
are  seen  in  diabetes,  uremia,  various  infectious 
disorders,  alcoholism  and  other  conditions,  these 
claims  have  much  weight.  The  toxic  substances 
may  be  of  intestinal  origin  as  result  of  abnor- 
mal-digestion or  absorption;  of  impaired  excre- 
tion ; changed  internal  secretion  or  from  external 
origin  such  as  from  alcohol.  The  toxic  sub- 
stances reported  .ma^--caus-e~--th£.  seizures,  but 
there  must  have  been  a predisposition  in  the 
individual  as  we  all,  without  doubt,  have  at  one 
time  or  another  similar  substances  circulating  in 
our  blood. 

However  prominent  the  exciting  cause  mav 
seem  in  some  cases,  the  predisposition  present  is 
practically  always  very  plain  if  a careful  study  of 
the  case  is  made. 

Although  the  general  medical  profession  still 
believe  in  numerous  reflex  epilepsies,  most  of 
these  observers  who  have  had  large  experience 
feel  with  Gowers,  Peterson  and  others,  that  the 
so-called  reflex  epilepsies  are  exceedingly  rare. 


7 


Although  these  conditions  may  be  corrected,  one 
seldom  sees  a complete  cessation  of  seizures  and 
in  many,  no  appreciable  effect  is  noted.  An 
epileptic  has  a nervous  system  more  susceptible 
to  influences  than  has  a normal  individual,  but 
that  such  reflex  causes  can  produce  the  disease  in 
an  otherwise  healthy  person,  I do  not  believe. 
The  hereditary  instability  of  the  cerebral  cortex 
is  the  ever  present  condition  we  must  consider. 
More  and  more  cases  of  so-called  idiopathic 
epilepsy  are  shown  to  have  an  organic  basis. 

The  chemical  changes  occurring  in  the  living 
nerve  cell  are  unknown  quantities  and  it  seems 
reasonable  to  believe  that  the  exact  exciting 
cause  of  the  development  of  the  symptoms  of 
epilepsy,  insanity,  etc.,  is  locked  within  these 
cell  limits  beyond  discovery  by  any  methods  now. 
known  to  us,  and  perhaps,  as  has  been  main- 
tained, may  never  be  known. 

As  referred  to,  the  various  forms  of  meningi- 
tis, cysts,  new  growths,  localized  hemorrhage, 
aneurism,  encephalitis  and  depressed  bone  are 
possible  causes  of  epilepsy. 

Surgical  removal  of  these  lesions  when  pos- 
sible may  relieve  but  too  often  we  find  the 
seizures  recur.  If  a portion  of  the  cortex  or  a 
part  which  presses  on  the  cortex  is  removed,  we 
must  necessarily  have  subsequent  cicatrisation  or 
other  changes  as  a result  of  which  a focus  of 
irritation  is  developed  to  continue  the  symptoms 
we  had  hoped  to  have  disappear.  The  removal 
of  a myxoma,  glioma  or  other  new  growth  of  the 
cortex  may  be  perfect  from  a surgical  standpoint 
and  still  the  symptoms  of  the  epilepsy  reappear 
within  a few  months  or  sooner.  Certain  altera- 
tions of  the  finer  structures  of  the  contiguous 


8 


parts  have  occurred  which  are  beyond  remedy  by 
use  of  the  knife.  Some  temporary  relief,  really 
marked  in  some  cases,  does  occur. 

As  L.  Pierce  Clark  pointed  out,  the  aura, 
except  when  motor  in  character,  is  entirely  sub- 
jective and  to  interpret  its  possible  localizing 
value,  all  the  fallacies  of  human  testimony  have 
to  be  reckoned  with  in  estimating  the  statements 
of  an  individual  who  is  in  the  majority  of 
instances  defective  mentally. 

Trephining  for  the  relief  of  epilepsy  is  of 
ancient  origin,  when  it  was  supposed  to  permit 
the  evil  spirit  to  escape.  It  was  used  extensively 
during  the  sixteenth  century. 

The  treatment  of  epilepsy  from  the  most  re- 
mote period  has  included  surgical  procedures,  j 
regarding  the  efficacy  of  which  there  has  always  S 
been  much  dispute.  One  writer  of  considerable 
note  states  that  after  a most  exhaustive  study  of 
surgical  treatment  of  essential  epilepsy,  he  con- 
cludes that  operation  is  useless.  Neither 
sympathectomy  nor  craniotomy  is  capable  of 
insuring  a lasting  improvement  or  permanent 
cure. 

How  many  persons  suffer  trauma  of  head  and 
elsewhere  and  never  develop  epilepsy?  The 
trauma  in  the  history  of  the  epileptic  are  simply 
incidental  in  many  instances.  Manley  reported 
that  in  a series  of  more  than  seven  hundred 
fractures  of  the  skull,  he  found  no  direct  evi- 
dence that  epilepsy  occurred  in  any  one  who  be- 
fore injury  did  not  give  a history  of  having  had 
symptoms  earlier  in  life. 

Kocher  claims  that  epilepsy  is  due  to  a general 
or  a local  exaggeration  of  the  intra-cranial  pres- 
sure. Opening  the  dura  acts  as  a safety  valve  to 
regulate  this  pressure  and  results  in  cure  in  many 


9 


cases.  Bergmann  claims  epilepsy  is  hereditary 
y in  90  per  cent,  of  the  cases,  and  whether  con- 
genital or  acquired,  bars  a successful  operation. 

Alexander,  of  Liverpool,  advocates  fenestra- 
tion of  the  dura  as  a method  of  relief. 

Many  observers  maintain  that  there  exists  a 
strong  relationship  between  all  epilepsies  and  the 
various  paralytic  states  of  the  brain,  indeed  Freud 
states  that  all  epilepsies  are  apoplectic  in  origin, 
either  intra  or  extra  uterine.  In  partial  support 
of  this,  we  must  admit  that  many  epileptics  fail 
on  superficial  examination  to  present  brain 
palsies,  but  a careful  search  many  times  reveals 
evidences  of  an  unrecognized  cerebral  palsy 
probably  dating  back  to  infancy. 

Sir  Victor  Horsley  reports  operating  on  five 
cases  of  idiopathic  epilepsy  of  localized  onset. 
Two  of  the  cases  had  proved  to  be  of  organic 
origin.  These  showed  to  him  that  an  exploratory 
operation  might  be  justifiable  in  cases  which  had 
resisted  medical  measures.  In  Jacksonian 
epilepsy  there  exists  a gross  lesion  or  a toxaemia. 
In  traumatic  cases  of  a Jacksonian  type,  the  con- 
vulsions may  be  generalized  or  localized.  Surgi- 
cal measures  are  not  by  any  means  uniformly 
successful ; in  localized  cases,  however,  trephin- 
ing is,  according  to  Horsley,  very  successful, 
particularly  when  the  scar  was  in  a so-called 
motor  area;  less  successful  when  the  scar  is  in 
the  occipital  region,  and  still  less  successful  when 
it  is  in  the  frontal  or  tempero-sphenoidal  region. 

It  should  be  borne  in  mind  that  neoplasms 
within  the  cranium  may  not  produce  localizing 
convulsions  but  cause  general  convulsions 
similar  to  those  seen  in  idiopathic  epilepsy. 
Cushing  tells  us  that  an  inversion  of  color  fields 
may  be  the  first  symptom  of  brain, tumor. 


10 


My  opinion  is  that  brain  tumor  and  traumatic 
cases  of  epilepsy  operated  on  early  before  several 
seizures  have  occurred  to  produce  permanent 
damage,  may  be  benefited  in  many  instances. 
Careful  after  treatment  with  sedation  where 
indicated  is  of  the  utmost  importance. 

We  must  remember  that  any  change  in  treat- 
ment, operative  or  not,  often  produces  much 
benefit  either  as  a result  of  closer  attention  to 
details  or  by  psychical  influence.  Do  not  forget 
that  many  patients  are  worse  after  trephining 
than  they  were  before. 

Alexander,  and  later  Jonnesco  and  many 
others,  have  practiced  cervical  sympathectomy  in 
epileptics  with  reports  of  a percentage  of  cure£ 
reaching  from  25  to  50  per  cent.  Jabculay  and 
Lannois  report  a series  of  sixteen  cases  in  which 
the  result  as  far  as  cure  was  nil.  I witnessed 
three  operations  of  this  nature  performed  at  the 
Craig  Colony  by  Dr.  Roswell  Park,  of  Buffalo, 
N.  Y.  One,  a male,  had  grand  mal  seizures  two 
or  three  times  a month  preceding  the  operation. 
Since  then  a period  of  six  years  has  elapsed  with 
a freedom  from  seizures.  He  is  now  practicing 
law  in  Cincinnati.  The  second,  a female,  had  her 
seizures  much  less  frequently  for  a time.  The 
third  case,  a female,  showed  no  improvement. 

The  epileptic  is  too  frequently  a degenerate 
with  an  abnormal  nervous  system  which  cannot 
be  readjusted  and  made  anew  by  operative  pro- 
cedure. The  congenital  defect  is  beyond  renova- 
tion by  surgical  skill. 

The  question  of  exhaustion  palsies  occurring 
in  epilepsy  may  be  due  to  a similar  cause  which 
produces  the  temporary  palsies  seen  in  uremia, 
that  is  arterial  spasm  and  localized  cerebral 
edema.  Cushing  and  Bordley,  as  a result  of 

11 


UNIVERSITY  OF 
ILLINOIS  LIBRA 


their  observations  on  their  cases  of  cerebral 
decompression/  came  to  the  conclusion  that  the 
local  and  transient  hemiplegias  and  aphasias, 
amauroses  and  Jacksonian  fits  or  uremia  are  also 
due  to  edema  of  the  brain.  What  can  operative 
intervention  do  for  these? 

The  etiological  influence  of  the  pelvic  organs 
of  the  female  in  the  production  of  the  phenomena 
of  epilepsy  has  been  argued  pro  and  con  for 
many  years.  In  my  opinion,  as  a consequence 
of  failure  to  find  the  alleged  close  relationship 
between  these  conditions,  we  must  seriously 
question  the  advisability  of  performing  opera- 
tions on  the  female  generative  organs  with  the 
idea  in  mind  of  gaining  anything  unless  it  be  an 
improvement  of  the  general  health  of  the 
individual  by  removing  some  pathological  con- 
dition. 

La  Place  and  Runyon  have  reported  epileptics 
markedly  relieved  as*  a result  of  appendicostomy 
with  subsequent  colonic  irrigations  over  an 
extended  period. 

Sieveking,  writing  some  sixty  years  ago  on 
epilepsy,  stated  with  much  wisdom  that:  “The 
air  the  patient  breathes,  the  water  he  drinks,  and 
his  ablutions,  his  daily  occupation  and  habits, 
his  amusements,  his  food  and  beverage,  his 
clothing,  his  mental  and  moral  history,  and  his 
prospects  in  life,  should  be  inquired  into  in  order 
to  determine  whether,  or  in  how  far,  one  or  more 
of  those  elements  require  modification.” 

These  matters  have  in  our  day  too  often  been 
neglected  by  the  physician.  All  abnormal  con- 
ditions of  the  nose,  eye,  teeth,  gastro-intestinal 
tract,  pelvic  organs  in  women,  etc.,  must  be  cor- 
rected if  possible  as  a basis  for  correct  treatment. 
In  order  that  proper  dietetic  and  hygienic  treat- 


12 


ment  be  carried  out,  the  epileptic  should  be 
placed  in  a special  institution  if  a properly 
trained  and  capable  nurse  or  companion  cannot 
be  secured  outside. 

A regular  occupation,  preferably  out  of  doors, 
is  very  essential  for  the  ablebodied  epileptic. 
Special  instruction  in  the  ordinary  school 
branches  and  especially  in  manual  training, 
should  be  arranged  for  the  younger  patients. 
This  is  important  to  inculcate  discipline  as  well 
as  for  the  knowledge  acquired. 

There  is  no  specific  medication  to  be  used  in 
epilepsy,  although  we  must  admit  that  proper 
♦ use  of  the  bromine  preparations  approaches  this 
in  selected  cases.  In  some  the  bromides  bring1 
about  a complete  cessation  of  seizures,  but  in 
most  instances  there  is  but  a diminution  in  the 
frequency  and  severity'  of  the  attacks.  In 
other  cases,  as  is  well  known,  the  bromides  seem 
to  exert  no  appreciable  influence  on  the 
symptoms. 

Bromism  is  not  necessary  to  produce  favorable 
results  where  such  are  to  occur.  Proper  regard 
for  diet,  hygiene,  especially  hydrotherapy,  and 
dosage  will  obviate  untoward  results. 

Bromides  should  be  given  early  and  continued^ 
over  a period  of  years.  If  a maximum  continued 
dose  of  from  75  to  90  grains  during  the  24  hours 
does  not  control  the  seizures  in  an  adult,  it  is 
not  wise  in  the  average  case  to  push  the  drug 
beyond  this  point. 

It  is  well  established  that  the  elimination  of 
sodium  chloride  from  the  diet  aids  materially  in 
producing  the  full  effect  of  the  bromides.  The 
potassium,  sodium  and  strontium  salts  are  most 
commonly  administered,  ordinarily  in  divided 
doses  and  usually  in  combination  in  an  elixir  and 


13 


well  diluted.  Other  bromine  preparations ; e.  g., 
bromipin,  brovalol,  bromoglidine,  brometone,  etc., 
may  be  used  as  more  elegant  medicaments. 
Where  associated  cardio-vascular  conditions 
exist,  digitalis,  strophanthus,  amyl,  nitrate,  nitro- 
glycerine, etc.,  prove  of  value.  Bechterew  recom- 
mends adonis  vernalis  with  bromides  and  Turner 
claims  to  have  obtained  good  results  following 
the  use  of  Gelineau’s  formula ; i.  e.,  Pot.  brom., 
i grm. ; picrotoxin,  1-3  mgrm.,  and  y2  mgrm. 
of  the  arseniate  of  antimony.  Turner  increases 
the  dose  until  six  such  doses  are  taken  daily. 
Belladonna,  borax,  chloretone,  simulo,  solanum 
carolinensis,  zinc  salts,  etc.,  have  never  given  me 
any  good  results. 

Contrary  to  what  is  often  taught,  strychnine 
can  be  used  without  fear  as  a stimulant  or  tonic 
where  indicated. 

During  the  past  year,  investigators  have 
claimed  much  benefit  resulting  from  the  giving  of 
calcium  lactate  but  a series  of  cases  at  Craig 
Colony  to  whom  it  was  exhibited  failed  to  show 
much  change  except  one  boy  whose  condition  did 
improve  some. 

The  treatment  of  serial  seizures,  status  epilep- 
ticus  and  the  various  mental  disorders  accom- 
panying epilepsy  is  of  great  importance.  Avoid- 
ance of  constipation,  proper  exercise,  a carefully 
regulated  diet  and  frequent  bathing  are  of  the 
utmost  value  as  prophylactic  measures.  When 
status  is  once  established,  the  gastro-intestinal 
tract  must  be  thoroughly  emptied  by  cleansing 
enemata  and  by  stomach  tube.  Then  chloral  or 
amylene  hydrate  by  enema  should  be  used 
judiciously  to  control  the  convulsions.  The 
bromides  are  of  but  little  value  in  this  condition. 


14 


Chloroform  may  be  given  in  the  early  stage  until 
some  chloral  has  been  absorbed.  Lumbar  punc- 
ture to  relieve  this  supposed  increased  intra- 
cranial tension  may  be  used  in  severe  cases. 
Venesection  is  used  in  plethoric  individuals. 
Cold  sponges  or  packs  are  of  great  value  to  con- 
trol the  temperature  which  may  be  elevated  to 
107  or  108  degrees.  For  stimulation,  where 
required,  I have  found  enemata  of  strong  black 
coffee  and  hypodermatic  injections  of  brandy  and 
aromatic  spirits  of  ammonia  to  act  very  nicely. 

After  the  convulsions  have  ceased,  a supportive  / 
diet  and  careful  nursing  are  all  important.! 
Watch  out  for  pneumonia  and  bed  sores. 
s For  the  mental  disturbances  close  supervision, 
nourishing  food,  due  attention  to  the  emunctories 
and  hydrotherapy  are  sufficient.  Where  insuf- 
ficient nursing  exists,  it  may  be  necessary  in 
markedly  maniacal  cases  to  use  hyoscine  hydro- 
bromate  hypodermically,  but  only  as  a last  resort. 
Continuous  warm'  baths  and  hot  packs  properly 
given  will  quiet  the  most  violent  case.  * 

The  diet  in  epilepsy  can  be  fairly  liberal 
avoiding  an  excess  of  meats  and  all  pastries, 
sweets,  etc.  Pork  is  usually  tabooed  but  I can- 
not see  how  a little,  if  well  cooked,  cannot  be 
allowed  occasionally.  Some  patients  do  better 
without  any  meat.  Cooked  cabbage  and  cauli- 
flower are  to  be  avoided.  The  food  must  be  well 
masticated,  not  bolted.  Unless  the  little  details 
in  diet  as  well  as  hygiene,  etc.,  are  carefully 
attended  to,  we  cannot  look  for  beneficial  results. 

For  chronic  cases  in  which  there  is  an  organic 
basis,  the  individuals  should  be  placed  in  the 
special  institution  where  with  his  fellow  sufferers 
he  may  lead  as  cheerful  an  existence  as  his  con- 

15 


# 


dition  will  permit.  He  can  have  regular  and 
congenial  occupation  and  recreation  with  a 
suitably  arranged  simple  life  with  avoidance  of 
all  undue  excitement.  Where  epileptoid  symp- 
toms are  apparently  due  to  abuse  of  alcohol,  total 
abstinence  must  be  insisted  upon.  Dietary  and 
hygienic  details  must  be  given  careful  attention. 
Oftentimes  in  these  cases  there  must  be  a radical 
change  in  the  environment  if  a favorable  out- 
come is  to  be  looked  for. 

Epilepsy  is  essentially  a chronic  disorder,  con- 
sequently treatment  must  be  continued  over  a 
long  period  of  years  and  in  all  instances  a closely 
regulated  mode  of  living  must  be  maintained 
throughout  the  remainder  of  life.  An  individual 
who  has  once  had  symptoms  of  epilepsy  and  they 
have  disappeared  may  have  a recurrence  owing 
to  his  pre-disposition. 

A fact  to  be  borne  in  mind  is,  that  a sudden 
withrawal  of  sedatives  from*  an  epileptic  may 
produce  a fatal  status  epilepticus.  The  use  of 
sera,  thyroid  and  other  glandular  extracts  has 
not  proved  to  be  as  valuable  as  was  promised, 
although  some  writers  still  report  marvelous 
results. 

The  use  of  quack  remedies  must  be  combatted 
as  they  usually  tend  to  seriously  injure  the 
individual. 

Altruistic  principles  make  us  feel  that  perma- 
nent segregation  of  defectives  is  a kindness  to 
these  unfortunates  and  a duty  owing  the  social 
body  at  lar gej  Asexualization  is  indicated  in 
many  instances  to  prevent  absolutely  the  pro- 
pagation of  these  individuals,  but  if  even  these 
are  turned  loose  in  the  community,  they  cannot 

16 


properly  adjust  themselves  to  their  environment. 
The  high  grade  defective,  even  though  pre- 
vented from  begetting  his  kind,  is  capable  of 
doing  much  harm  if  allowed  his  freedom.  All  of 
these  preventive  measures  cannot  blot  out  the 
army  of  defectives  as  a considerable  percentage 
are  recruited  from  parents  supposedly  approach- 
ing the  normal  average,  but  it  is  clearly  evident 
to  all  that  those  plainly  defective  should  not  be 
permitted  to  multiply  their  kind. 

Those  entering  into  the  married  state  should 
do  so  with  greater  knowledge  and  circumspec- 
tion than  is  now  the  case.  The  contracting 
parties  should  be  aware  of  what  will  unfailingly 
follow  certain  conditions. 

One  writer  of  experience  remarks  that  the 
time  should  soon  come  when  all  cases  of  epilepsy, 
feeblemindedness,  insanity,  criminality,  etc., 
should  be  reported  to  some  central  point  and 
accurate  records  kept  of  such  defectives. 

Before  any  material  results  can  be  obtained 
from  law  restricting  marriage  or  cohabitation,  we 
must  secure  the  active  co-operation  of  the 
general  public.  In  order  that  this  may  be 
brought  about,  it  will  be  necessary  to  carry  on 
for  years  or  even  generations  an  active  campaign 
of  education  to  create  a well  established  public 
sentiment  against  the  propagation  of  the  unfit. 
This  public  education  must  come  primarily 
through  the  efforts  of  the  physician,  especially 
the  general  practitioner.  This  subject  is  very 
old  as  you  all  know,  but  why  not  every  time  you 
can,  do  your  share  toward  teaching  what  can  be 
done  ? Physicians  in  general  must  begin  to 
tealize  the  seriousness  of  these  matters  and  the 


1 7 


great  necessity  of  exercising  such  means  of 
prophylaxis  as  are  readily  available. 

I have  for  your  inspection  a few  charts  pre- 
pared by  Dr.  Munson,  which  illustrate  very 
clearly  how  many  defectives  propagate  and  why 
their  marrying  should  be  systematically  dis- 
couraged. 

New  York  State  should  have  laws  with  proper 
penalties  attached,  prohibiting  the  inter-marriage 
or  cohabiting  without  marriage  of  those  plainly 
defective  such  as  the  epileptic,  feebleminded, 
insane,  confirmed  criminal,  inebriate,  etc.  These 
laws  should  also  make  it  a serious  offense  for 
any  person  of  sound  mind  to  marry  or  cohabit 
with  or  to  aid  others  in  marrying  or  cohabiting 
with  any  such  epileptic,  insane,  feebleminded, 
criminal  or  otherwise  mentally  defective  indi- 
vidual. 

Why  does  not  New  York  State  come  forward 
in  this  matter  of  prevention  as  well  as  it  has  in 
its  active  campaign  against  tuberculosis? 

After  considering  the  etiological  factors  and 
the  course  of  epilepsy,  one  can  readily  under- 
stand why  the  ultimate  prognosis  is  unfavorable 
in  such  a great  percentage  of  cases.  Many  re- 
spond to  proper  treatment  so  far  as  a diminished 
frequency  of  seizures  and  general  improvement 
of  health  is  concerned,  but  those  actually  cured 
are  comparatively  speaking  very  few  indeed. 

The  earlier  the  onset,  the  more  frequent  the 
seizures,  the  more  marked  the  general  deteriora- 
tion, the  worse  is  the  prognosis. 

The  period  that  an  epileptic  must  be  free 
from  seizures  to  be  considered  cured  varies  from 
two  years  to  a lifetime  according  to  the  par- 
ticular writer.  In  my  opinion,  if  an  epileptic  has 

18 


■O''™'*  • ®s • © w 

□ «.,  ®D,S'“'  sa  m'n“  eb m'M  m M 

j 

iil 

5 

it 

e 

1 i # ?’ 

a 

If 

u 
1 1 

t—  ...  ?’ 

1 

• c 

ii 

|Mi  tfvr 

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k i <2>  i 1 

t-Y* <Y\  Jine  ^ o Mers  n at  Xn a w» 

1 1* 

- ' 

|| 

Father  and.  tiro  daughters  were  patients  at  the  Colony  at  the  same 

time. 

1. 

19 


O'™-  • ©F«bl,-  © • @ 

■P"PU'  a -“■*  hT”  ®'"h0"“" 

ii1 

, -2 
•§  fi 
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jj 

[Patient  s sisters. 

1 brothers 

...Jl  A ’ 

Patient  * children,  1 

nephews,  heices, 

3. 

20 


been  free  from  seizures  for  from  two  to  four 
years,  they  can  be  pronounced  as  recovered  with 
the  explanation,  however,  that  seizures  may 
recur  later  in  life. 

Finally,  we  must  confess  that  our  prognosis 
does  not  differ  materially  from  Cooke  who  stated 
nearly  a century  ago  that : “Upon  the  whole,  the 
younger  the  subject,  the  less  frequent  and  less 
violent  the  attacks,  the  more  removable  the  excit- 
ing cause  and  the  shorter  the  time  to  which  the 
patient  has  been  subject  to  the  disorder,  the 
greater  the  probability  of  removal.  On  the  con- 
trary, when  the  disease  is  hereditary  or  of  long 
standing  and  the  attacks  frequent  and  violent, 
when  the  strength  is  much  diminished  and  the 
powers  of  the  mind  impaired,  the  more  desperate 
must  the  state  of  the  patient  be  considered.” 


21 


BROOKLYN  EAGLE  PRESS. 


A 


